The Health 202: The Senate health-care bill is suffering from crippling unpopularity, too

Senator Al Franken, a Democrat from Minnesota, speaks during a rally opposing the House health-care bill. (Zach Gibson/Bloomberg)

The Senate GOP health-care bill departs less from Obamacare than the House measure — yet the two remain close cousins. So will the Senate bill suffer from the same crippling unpopularity as the House version? It appears so.

Today, we’re waiting for an official estimate from the Congressional Budget Office of how many people would be covered under the Senate bill compared to under the Affordable Care Act, the law it seeks to overhaul.

Things didn’t go so great for the House GOP health-care bill earlier this spring when the CBO estimated that it would leave 23 million people uninsured. The score fed a major backlash against that bill, which is currently supported by just 30 percent of the public, according to a new Kaiser Family Foundation poll, which also found 51 percent support for the ACA.

Our best guess is the Senate bill will do a little better on the coverage front, but not by much, resulting in a big public image problem for Senate Majority Leader Mitch McConnell to deal with as he tries to push the measure across the finish line this week.

Even if the CBO says the Senate bill will cost fewer people their coverage, say, 18 million or 20 million people instead of the House bill’s 23 million, that won’t be enough to move the needle for Democrats, the health-care industry and others who opposed the House bill on the grounds it would ratchet the uninsured rate back up again — including four Republican governors whose states accepted the ACA’s Medicaid expansion.

Governors John Kasich of Ohio, Brian Sandoval of Nevada, Charlie Baker of Massachusetts and Larry Hogan of Maryland all issued separate statements last week criticizing aspects of the Senate measure, including the secrecy under which it was written as well as the impact it would have on state budgets and low-income residents, my colleague Sandhya Somashekhar reports. Each of their states have received billions more in federal dollars over the past to help them cover more Americans on Medicaid.

The health-care industry didn’t even wait for a CBO score to register discontent with the Senate bill over its cuts to Medicaid and less-generous insurance subsidies. Doctors, hospitals and patient groups overwhelmingly came out against the Senate’s Better Care Reconciliation Act when the details became clear last week.

State Medicaid directors plan to issue a statement today saying the bill’s slower Medicaid growth formula is “insufficient and unworkable.”

“No amount of administrative or regulatory flexibility can compensate for the federal spending reductions that would occur as a result of this bill,” the National Association of Medicaid Directors will say, according to a statement provided to The Health 202.

Not even the bill’s more generous premium subsidies (relative to the House bill), its two-year retention of extra Obamacare cost-sharing subsidies or its repeal of nearly all the ACA taxes won over the insurance industry. “We are not taking a support or oppose position,” Kristine Grow, spokeswoman for America’s Health Insurance Plans, told the Hill.

Senate Majority Leader Mitch McConnell walks on to the Senate floor on Thursday, following a meeting with Senate Republicans on his health-care bill. (AP Photo/Andrew Harnik)

McConnell made a clear play for the support of moderate senators in crafting his bill. It sticks close to the ACA’s subsidy structure, providing federal assistance to people earning up to 350 percent of the federal poverty level who are purchasing insurance on their own and pegging the subsidies to a benchmark plan.

It takes longer than the House bill to roll back the ACA’s Medicaid expansion, waiting to draw down all the extra federal payments until 2024. And it preserves more of the ACA’s insurer regulations than the House bill, including its requirement for insurers to cover people with preexisting conditions without charging them more.

So if the Senate bill still doesn’t please the health-care industry and those on the moderate end of the spectrum despite shifting in a leftward direction, it certainly doesn’t enthuse conservatives either, who wanted to see even more of Obamacare repealed and are now terming the Senate bill “Obamacare-lite.” Those who had panned the House bill for keeping much of the ACA in place sharply criticized the Senate bill too, or at least said it needs major changes for them to come on board.

The Koch network, which supports such prominent groups as Americans for Prosperity, is refusing to endorse the measure as it stands, my colleague James Hohmann reported over the weekend. The network is working with conservative allies behind the scenes to make changes to the bill.

“In all candor, we’ve been disappointed that movement is not more dramatic toward a full repeal or rollback (of the Affordable Care Act). But we’re not walking away,” Americans for Prosperity President Tim Phillips told hundreds of donors gathered Saturday for a three-day seminar. “We still think this can get done, but the Senate bill needs to get better.”

AFP came out against the first version of the House health-care bill earlier this spring. So did Heritage Action and FreedomWorks, and neither of those groups are backing the Senate bill in its current form either. From Heritage Action:

None of this opposition is likely to dissuade McConnell. If anything, it will motivate him to get the bill past the finish line faster so he can move on to other legislative priorities that aren’t so potentially damaging politically.

And McConnell is getting praise from a few on the right, who say the Senate bill solves some of the House bill’s problems by better targeting assistance to low-income Americans and giving states more flexibility through the ACA’s existing waiver structure. One of those is Avik Roy, a prominent health-care policy expert who has advised Mitt Romney, Rick Perry and Marco Rubio.

“For decades, free-market health-reform advocates have argued that the single best idea for improving U.S. health care is to maximize the number of Americans who can afford to buy health insurance for themselves, instead of having to depend on the government or their employer,” Avik wrote in a Post op-ed. “The Senate bill transforms the American health insurance landscape in this direction.”

Avik tweeted this shortly after the bill was released last Thursday:

Finished reading the Senate HC bill. Put simply: If it passes, it’ll be the greatest policy achievement by a GOP Congress in my lifetime.

–Now five Republican senators — one moderate and four conservatives — are saying they won’t support the Senate health-care bill without changes. Moderate Sen. Dean Heller (R-Nev.) became the fifth member joining the resistance when he expressed concerns about McConnell’s draft on Friday, my colleague Sean Sullivan reported.

Heller said he “cannot support a piece of legislation that takes away insurance from tens of millions of Americans and hundreds of thousands of Nevadans.” Three important factors to note here: Nevada expanded Medicaid under the ACA. Heller is up for reelection in 2018. And he’s the only Republican senator running for reelection in a state that went for Hillary Clinton last November. Heller’s statement doesn’t necessarily mean he’s ultimately going to vote against the Better Care Reconciliation Act, but it does mean McConnell would need to modify the legislation so as to give cover to Heller for supporting it.

Heller joins Sens. Ted Cruz of Texas, Rand Paul of Kentucky, Mike Lee of Utah and Ron Johnson of Wisconsin who are also opposing the bill in its current state. Those four have opposite concerns that it preserves too much of the ACA. This is a bad math equation for McConnell, who will not be able to pass the legislation if more than two Republicans defect. It sets up what my colleague Paul Kane calls a “final frenzy of negotiation.

–As McConnell scrambles to save the measure, he needs help from the Trump administration to win over the skeptical conservatives. At the same time, he is seeking a separate way of winning wary GOP moderates over whom Trump holds little political influence, such as Sens. Susan Collins (Maine) and Lisa Murkowski (Alaska.), who oppose the bill’s blockage of federal funding to Planned Parenthood, among other things.

–Groups on the right and left are starting a digital and television ad war in Nevada to sway Heller over to their side, my colleague Dave Weigel reports. America First Policies, one of several groups set up to back the president since his election, announced Friday that it would launch digital and TV ads asking Heller to change his stance. It summed up the message in a tweet:

The AARP has been running ads for some time asking Heller to vote no if the Republican health-care bill got to the Senate. This ad portrays an irate couple learning that “if you’re over 50, health-care companies can charge you five times more,” a dramatization of what AARP calls “the age tax:”

—Trump confirmed that he had called the House health-care bill “mean” behind closed doors, in an interview with Fox and Friends yesterday. Trump said former president Obama used his own term — “mean” — in a Facebook post Obama used to critique the Senate health-care bill.

“He used my term: ‘mean,’” Trump said. “That was my term, because I want to see — and I speak from the heart — that’s what I want to see. I want to see a bill with heart.”

Trump also conceded that “nobody can be totally happy” with the plan. “Forget about votes, this has nothing to do with votes,” he said. “This has to do with picking a plan that everybody’s going to like. I’d like to say love, but like.”

Over the weekend, Trump criticized Democrats for opposing the effort and expressed optimism that enough Republicans will come on board:

—Health and Human Services Secretary Tom Price said yesterday the Trump administration is in ongoing talks with the five Senate holdouts.

“We’re talking with every one of them,” Price said on Fox News Sunday. “Conversations are ongoing. That’s what we’re working on this week. That’s the legislative process. What we’re trying to do here, admittedly, is to thread a needle to make it so that, as the president says, every single American needs to be able to have access to the kind of coverage that they want.”

–And senior White House adviser Kellyanne Conway said Trump is “working the phones” on the bill,Politico reported. “He [Trump] is working the phones; he is having personal meetings,” Conway said on ABC’s “This Week.” “He hopes to get to yes.” Conway also said Democratic candidates defeated by Republicans in four special elections since November “all ran pretty much to keep Obamacare where it is.”

Here’s a video mashup of weekend reactions to the Senate health-care bill from Trump, Price and others:

AHH, OOF and OUCH

AHH: Want to understand how the Senate health-care bill would shift the level of subsidies low-income Americans can receive? The Post’s Kim Soffen has cooked up some cool graphics here.

OOF: The Senate Republican health-care bill would sharply break with pledges Trump made during the 2016 campaign to block reductions in Medicaid spending and to deliver tax cuts primarily to the middle class, the Post’s Damian Paletta writes. Yet it would achieve a historic convergence of GOP priorities, placing major, permanent caps on Medicaid spending and providing a significant tax cut for wealthy Americans.

“President Trump and congressional Republicans describe the legislation as fulfilling their promise to repeal the Affordable Care Act, or Obamacare, but key provisions are also aimed at making progress on the GOP’s long-held goal of cutting entitlement spending,” Damian writes.

“All together, it shows how long-term conservative goals of cutting taxes and entitlement spending have overtaken Trump’s agenda, as the bill faces critical votes in the Senate as soon as next week that could take it to the precipice of becoming law,” he continues. “Reducing taxes, Republicans argue, will boost the economy, and shrinking spending on programs such as Medicaid will slow the growth of the federal debt.”

Clinton also urged her more than 16 million Twitter followers to “speak out” against the Republican bill, linking to Obama’s Facebook post slamming the “fundamental meanness at the core of this legislation.”

–Obamacare premiums have soared in some places, but have they increased as much as President Trump says? Post fact-checker Michelle Ye Hee Lee examines a few claims about Alaska and Arizona he’s made recently:

“In Alaska, they’ve gone up 207 percent on Obamacare. You know, I used to mention only Arizona because they were up 116 percent in Arizona. Now Arizona is like good by comparison to some of the numbers. But they’re way up in Arizona, also.”— Trump, remarks at lunch with members of Congress, June 13

“Okay, so I have been saying all hundred and 116 percent for so long. That was Arizona. That was — so yesterday I have a new number — 204 percent in Alaska increase. It is a catastrophe.”— Trump, remarks at Faith and Freedom Coalition’s conference, June 8

The facts: Trump took his figures from a report by the Department of Health and Human Services which shows the average national premium on the individual market increased 105 percent from 2013 (before Obamacare’s major provisions took effect) to 2017, from $232 to $476. In Alaska, the average monthly premium increased to $1,041 in 2017 from $344 in 2016 — a 203 percent increase. That is among the highest percentage increases reported between those two years.

The caveat: The report doesn’t take into account the subsidies most marketplace enrollees are eligible for. Ninety-three percent of Alaska’s marketplace enrollees receive tax credits, Michelle reports. So even though the average premium cost increased 203 percent from 2013 to 2017, most people on the exchanges are paying far less than they did in 2013. In 2017, the 86 percent of people in the exchanges in Alaska who receive tax credits pay $93 per month — far less than the $344 they were paying in 2013.

The verdict: “Trump cherry-picks the high end of premium increases by selecting Alaska’s 203 percent increase, even though the average monthly premium across the country was up about 25 percent before subsidies,” Michelle writes. “But there are more problems. Trump uses the calculation of premium increases without incorporating the impact of tax credits — which most people in the exchanges receive. If you take the subsidies into account, the average monthly premium of most people in the individual market exchange goes down, not up…Trump earns Three Pinocchios.”

INDUSTRY RX

STATE SCAN

DAYBOOK

(Andrew Harrer/Bloomberg)

Coming Up

The Bipartisan Policy Center will hold an event Wednesday on cybersecurity and medical devices.

The Cato Institute will hold a briefing Wednesday on Capitol Hill on how the federal government should address the opioid crisis.

The Bipartisan Policy Center will hold an event on Thursday on balancing Medicaid cost and coverage.

American Enterprise Institute will hold an event on Thursday on the government’s role in medical innovation.

SUGAR RUSH

Watch 13 reactions to the Senate GOP health-care bill:

Sen. Joe Manchin (D-W.Va.) said the Senate can do an ‘awful lot’ to improve the Republican health-care bill: